and Jyothi G Seshadri2
Internal iliac artery ligation is a life-saving and, during postpartum hemorrhage, a uterus-saving procedure since it has no effect on future fertility or menstrual function [1]. This is probably because that internal iliac artery ligation helps control pelvic hemorrhage by greatly reducing the pulse pressure and not stopping blood flow entirely. Ligating the anterior division of the artery on both sides should theoretically stop blood flow through the superior and inferior vesical arteries since both arise from the anterior division. But there have been no reports of bladder necrosis or dysfunction either. This is because of the rich anastomosis in the pelvis [1–4]. Embolization of pelvic and uterine vessels by angiographic techniques can also be done to control pelvic hemorrhage. However, this depends on the availability of an intervention radiologist. And the angiographic uterine artery embolization in the setting of PPH (as opposed to embolization for leiomyoma) is associated with loss of circulation to lower extremities, labial and buttock necrosis, and vesicovaginal fistula in 3–5% of cases.
The technique of internal iliac artery ligation entirely depends on the ability of the obstetrician-gynecologist to quickly and correctly locate the bifurcation of the common iliac artery.
There are two ways to do it. The first approach involves dividing the round ligaments and opening the two folds of the broad ligament. The loose areolar tissues are quickly separated, and the iliac vessels are exposed right up to the bifurcation of the common iliac artery. All the structures should now be clearly visible—the common iliac artery with the ureter crossing it over its bifurcation, the external iliac artery which follows a long straight downward course and continues as the femoral artery in the lower limb. There is a blue vessel, much larger in caliber just under the external iliac artery which is the external iliac vein. And there will be a short vessel, the medial branch of the common iliac artery which runs a very short course of about 2 cm and immediately divides into the anterior and posterior divisions [2]. The gynecologist has to quickly gain access to this space without damaging any structure. In case of an LSCS, there will be dilated engorged ovarian vessels that might get damaged and lead to profuse bleeding in an already hemorrhaging patient.
Once the vessels are exposed, one must correctly identify the internal iliac artery. The vessels are seen pulsating, but ureter shows peristalsis. One must not ligate the external iliac artery or the ureter in the heat of the moment.
To ligate the internal iliac artery, a right-angled forceps is gently passed under it about 2 cm from the bifurcation of the common iliac artery. The internal iliac artery can be held or stabilized with a Babcock or a blunt forceps. The artery is lifted gently, without traumatizing the internal iliac vein. If veins are traumatized, dark red blood will be seen pouring out and this will only worsen the situation. A point where one can pass the right-angled forceps under the internal iliac artery is chosen. The assistant can feed a stout linen or silk into the right-angled forceps. The suture is tied preferably with sliding hand knots; not only is the situation an emergency, there will be many engorged vessels which can get traumatized if one tries to tie the knot with the needle holder. But if using a needle holder or an artery forceps to ligate, avoid taking the instrument close to the engorged vessels, lest they get traumatized. Because one is under a lot of stress, one must not apply so much energy to tie the knots that the ligature snaps. The iliac veins can get traumatized and will worsen the situation, if one repeatedly tries to pass the right-angled forceps under the internal iliac artery.
The procedure must be repeated on the other side. The area should be mopped and gentle pressure applied to check if bleeding is still persisting. One must doubly check if the wrong structure has been ligated. If external iliac artery is ligated, there will be no lower limb pulses—femoral, popliteal, posterior tibial, and dorsalis pedis will not be felt or will be very feeble if the ligature is not tight. The best medico-legal safety measure is to ask for another pulse oximeter and check for lower limb pulses and oxygen saturation. If both the pulse rate and the oxygen saturation in the lower limb are identical to that of upper limb, then one can conclude that the external iliac artery has not been ligated. Urine must be checked for hematuria, urine can be blood tinged due to handling and not necessarily due to ureteric injury.
This method, in author’s experience, is suitable for gynecological surgeries, especially during radical surgeries or when there is profuse hemorrhage in case of surgeries for large leiomyomas—myomectomy or hysterectomy. But in case of LSCS, one can approach the internal iliac artery through another route which gives faster access to the iliac vessels. The uterus is big even after delivery of the baby, about 24 weeks size, and the surrounding tissues are edematous and congested. Dividing the round ligaments and then trying to gain access to the axilla of the pelvis might itself lead to further bleeding if the engorged vessels are damaged. Also, bowels may be dilated, and the patient may be pushing/bearing down if she has been taken up in advanced labor. The visualization through a Pfannenstiel incision may not be adequate. One must ask for general anesthesia, and convert the Pfannenstiel incision to Maylard incision by extending the skin incision and dividing the rectus muscle. Ask for another assistant, exteriorize the uterus, and expose the pouch of Douglas. Hold the fold of peritoneum on the pouch of Douglas and make sure there is no structure underneath by feeling with thumb and index finger. Cauterize it and open the retroperitoneal space. Remember that the ureter is present along the fold of the broad ligament; it passes under the uterine artery to enter the tunnel of Wertheim. Feel the ureter with thumb and index finger and cut the peritoneum little by little.
By opening the pouch of Douglas, one can get quick access to the axilla of the pelvis—the bifurcation of the common iliac artery with the ureter crossing it. Make sure to correctly identify the structure. Pass a stout thread under the internal iliac artery with the help of a right-angled forceps, and tie it on both sides quickly and check if any wrong structure has been ligated in excitement and tension.
If the internal iliac artery ligation is done, it is advisable to close the abdomen with a drain in pouch of Douglas and give DVT prophylaxis from the second day of surgery. This should be done irrespective of whether internal iliac artery ligation was done in a gynecological surgery or following delivery. Drain is like a window and can tell what is happening inside the peritoneal cavity—Is the patient still bleeding? Pelvic surgery is a known risk factor for DVT and pregnancy is a known hypercoagulable state [5].
In case of profuse hemorrhage during laparoscopic surgeries, the ability to perform internal iliac artery ligation depends on many factors like obesity, difficulty level of the case, etc. When in doubt or when not having able assistants, one must convert the case into a laparotomy. The decision of taking a vertical or transverse incision depends on the difficulty level of the case. A transverse Maylard incision should work fine for internal iliac artery ligation alone.
But to perform the procedure laparoscopically, one must expose the bifurcation of common iliac artery by dividing the round ligament, and split open the two folds of broad ligament with a hook. Hold a small fold of the peritoneum with a grasper and lift it and cauterize it to enter the retroperitoneal space. Once the structures are exposed and identified, clips can be directly applied on the internal iliac artery using a clip applicator. The procedure is repeated on the other side, and one must check once again whether clips have been applied on the wrong structure.
Let us now study the photographs taken during live surgery, where sudden profuse bleeding was encountered and internal iliac artery ligation had to be done.
How to Locate the Internal Iliac Artery? (Fig. 11.1)
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